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The National Diabetes Prevention Program (NDPP) offers lifestyle change education to adults at risk for diabetes across the United States, but its reach is curbed due, in part, to limitations of traditional in-person programs. Diabetes Prevention Programs (DPPs) that are fully digital may increase reach by overcoming these barriers. The aim of this research was to examine the reach of Lark's DPP, a fully digital artificial-intelligence-powered DPP. This study assessed geographic features and demographic characteristics of a sample of Lark DPP commercial health plan members with complete data (N = 16,327) and compared several demographic features with a large composite sample of members from DPPs across the nation (NDPP; N = 143,489) and a National Health Interview Survey (NHIS) sample of prediabetic adults in the United States (NHIS; N = 2118). Examination of the Lark DPP sample revealed that 24.4% of members lived in rural areas, 30.8% lived in whole county health professional shortage areas, and only 7.6% of members lived in a zip code with an in-person DPP. When comparing the Lark sample with the NDPP and NHIS samples, Lark DPP enrollees tended to be younger and have a higher body mass index (BMI) (p's < 0.001). Lark provides convenient access to a DPP for individuals living in hard-to-reach areas who may face barriers to participating in in-person or telephonic DPPs or who prefer a digital program. Compared with the NDPP sample, Lark is also reaching younger and higher BMI users, who are traditionally difficult to enroll and have a high need for intervention. [ABSTRACT FROM AUTHOR]

Purpose of Review: There is a growing evidence base describing population health approaches to improve blood pressure control. We reviewed emerging trends in hypertension population health management and present implementation considerations from an intervention called Team-supported, Electronic health record-leveraged, Active Management (TEAM). By doing so, we highlight the role of population health managers, practitioners who use population level data and to proactively engage at-risk patients, in improving blood pressure control. Recent Findings: Within a population health paradigm, we discuss telehealth-delivered approaches to equitably improve hypertension care delivery. Additionally, we explore implementation considerations and complementary features of team-based, telehealth-delivered, population health management. By leveraging the unique role and expertise of a population health manager as core member of team-based telehealth, health systems can implement a cost-effective and scalable intervention that addresses multi-level barriers to hypertension care delivery. Summary: We describe the literature of telehealth-based population health management for patients with hypertension. Using the TEAM intervention as a case study, we then present implementation considerations and intervention adaptations to integrate a population health manager within the health care team and effectively manage hypertension for a defined patient population. We emphasize practical considerations to inform implementation, scaling, and sustainability. We highlight future research directions to advance the field and support translational efforts in diverse clinical and community contexts. [ABSTRACT FROM AUTHOR]

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Healthcare systems across high-income economies [1] are plagued by similar challenges, including an aging population, the increasing burden of chronic disease, and spiraling healthcare costs. David Kindig and Greg Stoddart defined population health as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group" [2], and there has been a deliberate move towards population health management to address much of these challenges. Population health management efforts do not just target populations that are sick or the hospitalized ("patient" population). It also involves ensuring that healthy populations receive preventive services to avoid onset of disease. In this editorial we consider this global move towards population health management in the context of Singapore's HealthierSG initiative. HealthierSG was announced by the Minister for Health in March 2022 and is a step forward in Singapore's population health journey. [ABSTRACT FROM AUTHOR]

Aims - We sought to identify patients with atrial fibrillation (AF) who are not prescribed anticoagulation (AC) to understand if such patients may be eligible for AC initiation. Methods - We queried the Mass General Brigham electronic health record to identify patients with AF apparently eligible for but not prescribed AC. Specifically, we identified patients with an outpatient encounter for AF or updated diagnosis of AF between January and March 2019 who did not have an active AC prescription. We then conducted physician chart review to determine if the patient was actually prescribed AC and if not, the reason why. We summarized results and present descriptive statistics. Results - Of 152 patients confirmed to have AF and confirmed to be off AC after chart review, 11/152 (7.2%) had a CHA2DS2-VASc of zero or were female with a score of one. 23/152 (15.1%) patients were not prescribed AC because their AF was transient and 21/152 (13.8%) patients declined AC. 39/152 (25.7%) patients either had physician-assessed elevated risk for bleeding or a history of bleeding before or after AC initiation. 6/152 (3.9%) patients were non-adherent, 13/152 (8.6%) had left atrial appendage occlusion device placed greater than 6 months previously, and 1/152 (0.7%) patient was lost to follow-up. The remaining 38/152 (25.0%) patients were apparently eligible for AC and present a potential quality improvement opportunity. Conclusion - In this sample of patients with AF who were confirmed to not be prescribed AC, the majority had provider-documented clinical justification to not be on AC. However, 25% of patients identified would likely be eligible for AC and could be the target of population-based quality improvement interventions. [ABSTRACT FROM AUTHOR]

The article describes an approach to coordinate ambulatory pharmacy within Mass General Brigham, an integrated health system. Topics discussed include background and impetus for the work, goals that were developed including forecasting, guideline development and implementation, and accomplishments over five years.

Social determinants of health (SDOH) are the greatest predictors of one's health status. There are clear SDOH disparities present in the United States, many of which have been especially evident during the COVID pandemic. SDOH have become a greater focus of payers, including Centers for Medicare & Medicaid Services (CMS). CMS has updated the reimbursement structure of Medicare and Medicaid to incentivize more SDOH-related interventions. Providers are also growing increasingly attentive to the SDOH needs of their patients, but often are unable to sufficiently address them outside of care settings. The combination of increased SDOH funding with inefficient mechanisms to meet patients' SDOH needs has led to the emergence of the for-profit SDOH industry. The purpose of this paper was to investigate the industry and identify its size, scope, and future implications. The authors conducted an analysis of for-profit SDOH companies using a third-party industry research platform. A collection of 58 companies was identified with $2.4 billion in funding and a total valuation of over $18.5 billion as of July, 2021. Two literature searches were conducted to support strategy recommendations for critically evaluating SDOH outcomes from these companies, and to determine the downstream effects they will have on community-based organizations also working to improve SDOH. [ABSTRACT FROM AUTHOR]

Abstract Background Population health management (PHM) by hospital groups is not yet defined nor implemented in France. However, in 2019, the French Hospitals Federation launched a pilot program to experiment PHM in five territories around five Territorial Hospital Groups (GHT’s). In order to implement PHM, it is necessary to firstly define the population which healthcare facilities (hospitals) have responsibility for. In the French healthcare system, mapping of health territories however relies mainly on administrative data criteria which do not fit with the actual implementation of GHT’s. Mapping for the creation of territorial hospital groups (GHTs) also did not include medical criteria nor all healthcare offers particularly in private hospitals and primary care services, who are not legally part of GHT’s but are major healthcare providers. The objective of this study was to define the French population groups for PHM per hospital group. Methods A database study based on DRG (acute care, post-acute and rehabilitation, psychiatry and home care) from the French National Hospitals Database was conducted. Data included all hospital stays from 1 January 2016 to 31 December 2017. The main outcome of this study was to create mutually exclusive territories that would reflect an accurate national healthcare service consumption. A six-step method was implemented using automated analysis reviewed manually by national experts. Results In total, 2840 healthcare facilities, 5571 geographical zones and 31,441,506 hospital stays were identified and collated from the database. In total, 132 GHTs were included and there were 72 zones (1.3%) allocated to a different GHTs. Furthermore, 200 zones were manually reviewed with 33 zones allocated to another GHT. Only one area did not have a population superior to 50,000 inhabitants. Three were shown to have a population superior to 2 million. Conclusions Our study demonstrated a feasible methodology to define the French population under the responsibility of 132 hospital groups validated by a national group of experts.

Abstract Background Advances in genetics and sequencing technologies are enabling the identification of more individuals with inherited cancer susceptibility who could benefit from tailored screening and prevention recommendations. While cancer family history information is used in primary care settings to identify unaffected patients who could benefit from a cancer genetics evaluation, this information is underutilized. System-level population health management strategies are needed to assist health care systems in identifying patients who may benefit from genetic services. In addition, because of the limited number of trained genetics specialists and increasing patient volume, the development of innovative and sustainable approaches to delivering cancer genetic services is essential. Methods We are conducting a randomized controlled trial, entitled Broadening the Reach, Impact, and Delivery of Genetic Services (BRIDGE), to address these needs. The trial is comparing uptake of genetic counseling, uptake of genetic testing, and patient adherence to management recommendations for automated, patient-directed versus enhanced standard of care cancer genetics services delivery models. An algorithm-based system that utilizes structured cancer family history data available in the electronic health record (EHR) is used to identify unaffected patients who receive primary care at the study sites and meet current guidelines for cancer genetic testing. We are enrolling eligible patients at two healthcare systems (University of Utah Health and New York University Langone Health) through outreach to a randomly selected sample of 2780 eligible patients in the two sites, with 1:1 randomization to the genetic services delivery arms within sites. Study outcomes are assessed through genetics clinic records, EHR, and two follow-up questionnaires at 4 weeks and 12 months after last genetic counseling contactpre-test genetic counseling. Discussion BRIDGE is being conducted in two healthcare systems with different clinical structures and patient populations. Innovative aspects of the trial include a randomized comparison of a chatbot-based genetic services delivery model to standard of care, as well as identification of at-risk individuals through a sustainable EHR-based system. The findings from the BRIDGE trial will advance the state of the science in identification of unaffected patients with inherited cancer susceptibility and delivery of genetic services to those patients. Trial registration BRIDGE is registered as NCT03985852 . The trial was registered on June 6, 2019 at clinicaltrials.gov .

[Display omitted] Despite increased availability of methodologies to identify algorithmic bias, the operationalization of bias evaluation for healthcare predictive models is still limited. Therefore, this study proposes a process for bias evaluation through an empirical assessment of common hospital readmission models. The process includes selecting bias measures, interpretation, determining disparity impact and potential mitigations. This retrospective analysis evaluated racial bias of four common models predicting 30-day unplanned readmission (i.e., LACE Index, HOSPITAL Score, and the CMS readmission measure applied as is and retrained). The models were assessed using 2.4 million adult inpatient discharges in Maryland from 2016 to 2019. Fairness metrics that are model-agnostic, easy to compute, and interpretable were implemented and apprised to select the most appropriate bias measures. The impact of changing model's risk thresholds on these measures was further assessed to guide the selection of optimal thresholds to control and mitigate bias. Four bias measures were selected for the predictive task: zero-one-loss difference, false negative rate (FNR) parity, false positive rate (FPR) parity, and generalized entropy index. Based on these measures, the HOSPITAL score and the retrained CMS measure demonstrated the lowest racial bias. White patients showed a higher FNR while Black patients resulted in a higher FPR and zero-one-loss. As the models' risk threshold changed, trade-offs between models' fairness and overall performance were observed, and the assessment showed all models' default thresholds were reasonable for balancing accuracy and bias. This study proposes an Applied Framework to Assess Fairness of Predictive Models (AFAFPM) and demonstrates the process using 30-day hospital readmission model as the example. It suggests the feasibility of applying algorithmic bias assessment to determine optimized risk thresholds so that predictive models can be used more equitably and accurately. It is evident that a combination of qualitative and quantitative methods and a multidisciplinary team are necessary to identify, understand and respond to algorithm bias in real-world healthcare settings. Users should also apply multiple bias measures to ensure a more comprehensive, tailored, and balanced view. The results of bias measures, however, must be interpreted with caution and consider the larger operational, clinical, and policy context. [ABSTRACT FROM AUTHOR]

Date Presented 03/23/24 This research explored older adults living in affordable housing and their views of social determinants of health and health management. The findings provide a better understanding of the role of personal factors of age and socioeconomic status on health management. Primary Author and Speaker: Kathleen (Kay) Cahill Graham Contributing Authors: Bailey Lester, Ziwang Long, Michaela Williams, Lanisha Mitchell [ABSTRACT FROM AUTHOR]

Background: We studied collaborative governance at the start of an integrated community approach aiming to improve population health, quality of care, controlling health care costs and improving professional work satisfaction. Our objective was to investigate which characteristics of collaborative governance facilitate or hamper collaboration in the starting phase. This question is of growing importance for policymakers and health initiatives, since on a global scale there is a shift towards 'population health management' where collaboration between stakeholders is a necessity. In addition, it is crucial to investigate collaborative governance from the beginning, since it offers opportunities for sustainability of collaboration later on in the process.Methods: We performed a qualitative case study in four deprived neighbourhoods in the city of Maastricht, the Netherlands. An integrated community approach was implemented, involving various stakeholders from the public and private health sectors and provincial and local authorities. Data was collected from December 2016 to December 2018, with a triangulation of methods (50 observations, 24 interviews and 50 document reviews). The Integrative Framework for Collaborative Governance guided data collection and analysis.Results: We focused on the dynamics within the collaborative governance regime, consisting of principled engagement, shared motivation and capacity for joint action. We found that shared goalsetting, transparency, being physically present, informal meetings, trust and leadership are key aspects at the start of collaborative governance. An extensive accountability structure can both hamper (time-consuming which hinders innovation) and facilitate (keep everybody on board) collaboration. The characteristics we found are of significance for policy, practice and research. Policymakers and practitioners can use our lessons learned for implementing similar (population health) initiatives. This case study contributes to the already existing literature on collaborative governance adding to the knowledge gap on the governance of population health approaches.Trial Registration: NTR6543 , registration date; 25 July 2017. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to verify the validity and reliability of the Korean version of the Health Care Empowerment Questionnaire (K-HCEQ) after translating it into Korean. Methods: Items were verified after translating the HCEQ into Korean, followed by back-translation and evaluation of content validity. The questionnaire survey was administered to 200 community-dwelling individuals aged >65 years. Construct validity and criterion validity were evaluated, and Cronbach's a was used to assess the reliability of the scale. Results: The final instrument consisted of three sub-factors and 10 items, as shown by confirmatory factor analysis. Moreover, the criterion-related validity showed a correlation coefficient of .50 (p<.001), confirming the validity of the developed instrument. Cronbach's a for all items was .94, and Cronbach's a of the sub-factors ranged between .88 and .93. Conclusion: The Korean version of the HCEQ for the elderly is an objective indicator that can be used to evaluate the effectiveness of health education programs aimed at older adults, thereby improving their health care empowerment. [ABSTRACT FROM AUTHOR]

Résumé: Face aux défis planétaires de biodiversité et de changements globaux, les aires protégées (AP) sont armées pour agir dans la préservation des trois santés : humaine, animale et écosystémique. Les AP françaises jouent un rôle pivot comme sites privilégiés de la mise en pratique du concept « Une seule santé ». Les AP appliquent un modèle concret territorialisé de système socio-écologique basé sur l'interdépendance entre société humaine et nature et sur une dynamique d'échanges de biens et de services écosystémiques et anthropiques. Elles disposent d'un panel d'outils ayant pour but le maintien d'un bon équilibre global. Valorisant des exemples opérationnels de mise en pratique du concept « Une seule santé » sur le terrain, l'article fournit une boîte à outils déclinée en quatre grandes catégories d'action favorisant le bon fonctionnement des systèmes socio-écologiques. Les outils de pérennisation y sont illustrés par les réseaux sentinelles alpins. Les outils d'équilibration détaillent le rôle fondamental et certains principes de gestion de la faune sauvage. Les outils de gouvernance variés fournissent des cadres contractuels et adaptés aux territoires. Enfin, les outils d'ouverture sont présentés comme des éléments clés permettant la mise en réseau d'acteurs et la construction de solutions fondées sur la nature. Les AP sont ainsi les interfaces privilégiées d'action, directement connectées aux objectifs de développement durable de l'Agenda 2030, garantissant notamment la santé et le bien-être pour tous. Protected areas (PAs) are intended to preserve the health of humans, animals and ecosystems and to meet the global challenges of biodiversity and climate change. The key role of French PAs as preferential sites for turning the " One health " concept into practice is highlighted. PAs apply a practical territorial model of socio-ecological systems based on the interdependence between human society and nature and on an exchange of ecosystem and anthropic goods and services. They have a range of tools for maintaining good overall stability. By highlighting operational examples of applying the " One health " concept, the article provides a toolbox divided into four main categories of actions to promote the proper functioning of socio-ecological systems. Sustainability tools are illustrated by the alpine sentinel networks. The stabilization tools set forth the fundamental role of wildlife and some principles of its management. The various governance tools provide contractual frameworks adapted to the various territories. Finally, integrating tools are presented as key elements to network actors and construct nature-based solutions. PAs are thus the most appropriate interfaces for action directly linked to the sustainable development objectives of the 2030 Agenda, guaranteeing, in particular, health and well-being for all. [ABSTRACT FROM AUTHOR]

Purpose To describe the development of a pilot specialty medication clinical dashboard targeting tumor necrosis factor (TNF)-α inhibitor therapy. Summary This was a quality improvement project conducted between August 2019 and April 2020. The dashboard was designed with collaboration between clinical pharmacists and specialty providers in rheumatology, gastroenterology, and dermatology. Data was queried from the Veterans Affairs Corporate Data Warehouse. Patients with an active prescription or intravenous order for a TNF-α inhibitor were included. Dashboard flag criteria focused on TNF-α inhibitor safety and adherence monitoring. Flag results from the dashboard were characterized from data captured at a single time point. For 431 patients on TNF-α inhibitor treatment at the institution, 304 flags corresponding to 223 unique patients (51.7%) were identified on the dashboard: 3% of patients had a new infection, 9% had overdue monitoring laboratory tests, 5% had a critical laboratory result, 2% were on 2 biologic agents, 27% were overdue for a refill, 6% had an emergency department visit, and 2% had an inpatient admission. No patients were flagged for heart failure exacerbation or new malignancy. Seventeen percent of patients were prescribed high-dose etanercept or adalimumab, representing a potential annual cost savings of $302,497 if 50% of these patients had their dose successfully reduced to labeled dosing. Opportunities for pharmacist intervention utilizing the dashboard were identified and characterized through chart review of flagged patients. Conclusion Pharmacists have the opportunity to improve safety and adherence for TNF-α inhibitor therapy through use of a specialty medication clinical dashboard. The dashboard should be used in conjunction with collaborative practice protocols. [ABSTRACT FROM AUTHOR]

Nonemergency medical transportation benefits, often using smartphone application-based ridesharing services, are increasingly being offered as part of population health management programs. However, the impact of these programs on health care use and costs remains understudied. We conducted a mixed-methods evaluation of a nonemergency medical transportation benefit offered to members of a Medicare accountable care organization (ACO) within a large academic health system, the UNC Health Alliance ACO. Participation in the transportation program was associated with a greater number of per person per year outpatient visits (9.2) and higher outpatient spending ($4,420) than in a comparison group. However, there was no difference in inpatient admissions or emergency department visits, and the program was not cost saving. Qualitative analyses revealed that participants were highly satisfied with the program, reporting that it eased financial burdens and made them feel safer, more empowered, and better able to take control of their health. These findings suggest that although transportation programs are commonly introduced as ways to contain health care spending, it may be better to think of them as programs to improve health care access for people facing difficult circumstances. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the feasibility and success of a pharmacist-led, targeted inhaled corticosteroid (ICS) de-escalation process in patients with chronic obstructive pulmonary disease (COPD) where the risks of ICS therapy outweigh the potential benefits. Methods: A population health data management tool was leveraged to identify patients who may qualify for ICS de-escalation. Primary care pharmacists clinically reviewed and subsequently contacted patients who were determined to be appropriate candidates. After discussion on the risks and benefits of ICS therapy, a stepwise algorithm was utilized to assist with ICS de-escalation and optimization of bronchodilator therapy. Outcomes analyzed include the proportion of patients for whom ICS was de-escalated, patient acceptability of the intervention, time taken to complete the intervention, barriers to implementation, and the number of additional interventions made by pharmacists. Results: Of the 126 patients originally identified as potential candidates, 58 (46.0%) were deemed appropriate to proceed with ICS de-escalation and successfully contacted by a pharmacist. Of these patients, 49 (84.5%) were agreeable and ultimately 42 were successfully de-escalated with 37 patients maintained off ICS. The average time required for an encounter was 15.8 minutes. Conclusion: There is utility in a pharmacist-driven, targeted ICS de-escalation process to facilitate meeting guideline-directed medication therapy goals in patients with COPD, granted the availability of efficient tools to assist in identifying patients that qualify. Such a targeted approach increases pharmacist involvement in medication management of COPD and can expand the primary care pharmacy practice.

Aims: Type 2 Diabetes Mellitus morbidity disproportionally effects the most socioeconomically deprived 20 % of England. Total Diet Replacement (TDR) is a high impact intervention currently commissioned by Integrated Care Boards (ICB). Finding and referring eligible, motivated patients is a significant challenge. This study evaluates a 12-month population health management, proactive referral intervention commissioned by Nottingham and Nottinghamshire ICB during a 2-year TDR pilot designed to supplement referrals from primary care., Methods: A Diabetes specialist nurse clinically reviewed a list of potentially eligible patients found by searching routinely collected health care data from 16 primary care centres in 3 PCNs., Results: 19.7 % (50/254) of potential patients were referred during the intervention period. 19.3 % (49/254) were uncontactable. 39.8 % (101/254) declined referral. 17.7 % (45/254) were ineligible after clinical review. An interrupted time series analysis suggests monthly referrals increased during the study period due to the intervetion (F (1,22) = 5.19 p=0.0345). Searching for patients from more socioeconomically deprived areas (index of multiple deprivation deciles 1-3) did not meaningfully alter the referral yield (19.6 %, 19/97)., Conclusions: Proactive care interventions could be used to facilitate referrals to the TDR or other high impact interventions by healthcare commissioning bodies., Competing Interests: Declaration of Competing Interest S Wormall is a General Practitioner, member of the Nottingham and Nottinghamshire Integrated Care Board (ICB) Clinical Design Authority and involved in the ICB management of the TDR pilot and Path to Remission programme. S Wormall has been supported as In-Practice Fellow by the Department of Health and Social Care and the National Institute for Health Research (NIHR). Karen Richardson is a Diabetes Specialist nurse working for Primary Integrated Care Services and delivered the PRI evaluated in this article. The views expressed are those of the author(s) and not necessarily those of Nottingham and Nottinghamshire ICB, the NHS, the NIHR, or the Department of Health., (Crown Copyright © 2024. Published by Elsevier Ltd. All rights reserved.)

The integration of medical schools and clinical partners is effectively established through the formation of academic medical centers (AMCs). The tripartite mission of AMCs emphasizes the importance of providing critical clinical services, medical innovation through research, and the education of future health care leaders. Although AMCs represent only 5% of all hospitals, they contribute substantially to serving disadvantaged populations of patients, including an estimated 37% of all charity care and 26% of all Medicaid hospitalizations. Currently, most AMCs use a business model centered upon revenue generated from hospital services and/or practice plans. In the last decade, mounting financial demands have placed significant pressure on AMC finances because of the rising costs associated with complex clinical care and operating diverse graduate medical education programs. A shift toward population health-centric health care management strategies will profoundly influence the predominant forms of health care delivery in the United States in the foreseeable future. Health systems are increasingly pursuing new strategies to manage financial risk, such as forming Accountable Care Organizations and provider-sponsored plans to provide value-based care. Refocusing research and operational capacity toward population health management fosters collaboration and enables reintegration with hospital and clinical partners across care networks, and can potentially create new revenue streams for AMCs. Despite the benefits of population health integration, current literature lacks a blueprint to guide AMCs in the transformation toward sustainable population health management models. The purpose of this paper is to propose a modern conceptual framework that can be operationalized by AMCs in order to achieve a sustainable future. [ABSTRACT FROM AUTHOR]

Approximately 1 in 3 American adults has prediabetes, a condition characterized by blood glucose levels that are above normal, not in the type 2 diabetes ranges, and that increases the risk of developing type 2 diabetes. Evidence-based treatments can be used to prevent or delay type 2 diabetes in adults with prediabetes. The American Medical Association (AMA) has collaborated with health care organizations across the country to build sustainable diabetes prevention strategies. In 2017, the AMA formed the Diabetes Prevention Best Practices Workgroup (DPBP) with representatives from 6 health care organizations actively implementing diabetes prevention. Each organization had a unique strategy, but all included the National Diabetes Prevention Program lifestyle change program as a core evidence-based intervention. DPBP established the goal of disseminating best practices to guide other health care organizations in implementing diabetes prevention and identifying and managing patients with prediabetes. Workgroup members recognized similarities in some of their basic steps and considerations and synthesized their practices to develop best practice recommendations for 3 strategy maturity phases. Recommendations for each maturity phase are classified into 6 categories: (1) organizational support; (2) workforce and funding; (3) promotion and dissemination; (4) clinical integration and support; (5) evaluation and outcomes; (6) and program. As the burden of chronic disease grows, prevention must be prioritized and integrated into health care. These maturity phases and best practice recommendations can be used by any health care organization committed to diabetes prevention. Further research is suggested to assess the impact and adoption of diabetes prevention best practices. [ABSTRACT FROM AUTHOR]

The issue of generalist versus specialist palliative care is on the minds of healthcare leaders everywhere. We are amid changing demographics of physicians. The industrialization of medicine is well underway in the US and around the developing world. Is it important to identify patients who benefit the most from specialist palliative care, given that it is currently a limited resource? Should we step out of standard practice and redesign palliative care using principles of population management? The COVID pandemic rapidly introduced virtual palliative care consults. Is it a better way to promote wide access to specialty palliative care? Looking forward, should we promote ways to advance primary palliative care and reserve specialty palliative care to patients who will benefit most from this level of care? These questions, and others, are considered in this transcribed discussion between leading physicians in the field. [ABSTRACT FROM AUTHOR]

Objective: The Project for Strengthening the ASEAN Regional Capacity on Disaster Health Management (ARCH Project) developed Regional Collaboration Drills (RCDs) and is proposing an ASEAN Academic Network to strengthen capacity in disaster health management (DHM) in ASEAN Member States (AMS), as well as developing a standard training curriculum in DHM. This study aims to clarify the impacts and sustainability of the ARCH Project. Methods: The four previous RCDs and the enhancement of academic activities were reviewed. Results: The ARCH Project developed the RCDs with simulation exercises based on possible disaster scenarios in each host country to test and validate the capacity of AMS International Emergency Medical Teams (I-EMTs), the Standard Operating Procedure (SOP) for I-EMT coordination, and regional tools, as well as the relevant domestic SOPs of the host countries for receiving international assistance. Following the RCD in Thailand, three AMS: Viet Nam, Philippines, and Indonesia, all of which are considered disaster-prone, successfully hosted RCDs with significant improvements. The project also established a sub-working group (SWG) to develop a standard curriculum in DHM. Two curricula developments, the Basic Course on DHM and In-Country Course for Coordination on EMTs, are on-going as part of the project activity. The establishment of the ASEAN Academic Network and the ASEAN Institute for DHM (AIDHM) are currently in the endorsement process of the ASEAN health sector. Conclusion: The RCDs are very effective to test and to validate the SOP and regional tools developed, providing opportunities for AMS I-EMT to familiarize the tools, as well as for host countries to assess their coordination capacity for receiving international assistance and identifying the country's specific challenges, and verifying ASEAN regional coordination mechanism. The development of the standard curriculum can enhance regional capacity both in supporting disaster-affected countries and in receiving international assistance. A sustainable capacity development mechanism in DHM is envisaged through the establishment of the ASEAN Academic Network and AIDHM toward the goal of One ASEAN One Response. [ABSTRACT FROM AUTHOR]

Background: Southeast Asia is the second biggest region in the world in terms of the total number of natural disasters since 1900. Therefore, the Association of Southeast Asian Nations (ASEAN) initiated regional challenges toward strengthening regional collaboration for disaster prevention and response since the earthquake of Sumatra in Indonesia occurred in 2004. Moreover, ASEAN Leaders signed "the ASEAN Declaration on One ASEAN, One Response" in 2016. Under these circumstances, ASEAN decided to implement the Project for Strengthening the ASEAN Regional Capacity on Disaster Health Management (ARCH Project). Objectives: The objective of the ARCH Project is to strengthen coordination on disaster health management (DHM) for rapid and effective response to disasters occurring in the ASEAN region and to enhance the capacity of each ASEAN Member State (AMS) on DHM. This article aims to overview the outline and its strategy, and review the progress of the project. Methods: ARCH Project is an ASEAN official project supported by Japan's official development assistance. Five outputs were launched for: (1) coordination platform on DHM; (2) framework of regional collaboration practices; (3) tools for effective regional collaboration; (4) enhancement of academic network on DHM; and (5) capacity development activities for each AMS. The Project was reviewed in terms of accomplishment and evaluation criteria. Results: Regional Coordination Committee on DHM was established as a coordination platform to: Oversee the implementation of the ARCH Project for the Output 1; Regional Collaboration Drill was developed and conducted for the Output 2; The standard operating procedure for coordination of emergency medical teams (EMTs) in ASEAN was developed for the Output 3; Various presentations on ARCH were made in academic conferences for the Output 4; and Several training programs and educational curricula were developed for the Output 5. The Project has accomplished its Project Purpose and satisfied all the indicators set. ARCH Project has high Relevance, Impact, Sustainability, and Effectiveness, while some improvements in Efficiency are needed. Conclusions: ARCH Project is the first-ever successful regional cooperation mechanism and standardization of DHM in ASEAN, one of the most disaster-prone regions. It also contributes to the capacity building of AMS. The ARCH Project has a remarkable impact on the resilience and flexible medical response to disasters, although continuous efforts of stakeholders to make this initiative sustainable are necessary. [ABSTRACT FROM AUTHOR]

Population Health Management typically relies on subjective decisions to segment and stratify populations. This study combines unsupervised clustering for segmentation and supervised classification, personalised to clusters, for stratification. An increase in cluster homogeneity, sensitivity and positive predictive value was observed compared to an unlinked approach. This analysis demonstrates the potential for a cluster-then-predict methodology to improve and personalise decisions in healthcare systems. [ABSTRACT FROM AUTHOR]

Background: Current measures to monitor population health include indicators of (i) average length-of-life (life expectancy), (ii) average length-of-life spent in good health (health expectancy), and (iii) variability in length-of-life (lifespan inequality). What is lacking is an indicator measuring the extent to which healthy lifespans are unequally distributed across individuals (the so-called 'healthy lifespan inequality' indicators). Methods: We combine information on age-specific survival with the prevalence of functional limitation or disability in Spain (2014–2017) by sex and level of education to estimate age-at-disability onset distributions. Age-, sex- and education-specific prevalence rates of adult individuals' daily activities limitations were based on the GALI index derived from Spanish National Health Surveys held in 2014 and 2017. We measured inequality using the Gini index. Results: In contemporary Spain, education differences in health expectancy are substantial and greatly exceed differences in life expectancy. The female advantage in life expectancy disappears when considering health expectancy indicators, both overall and across education groups. The highly educated exhibit lower levels of lifespan inequality, and lifespan inequality is systematically higher among men. Our new healthy lifespan inequality indicators suggest that the variability in the ages at which physical daily activity limitations start are substantially larger than the variability in the ages at which individuals die. Healthy lifespan inequality tends to decrease with increasing educational attainment, both for women and for men. The variability in ages at which physical limitations start is slightly higher for women than for men. Conclusions: The suggested indicators uncover new layers of health inequality that are not traceable with currently existing approaches. Low-educated individuals tend to not only die earlier and spend a shorter portion of their lives in good health than their highly educated counterparts, but also face greater variation in the eventual time of death and in the age at which they cease enjoying good health—a multiple burden of inequality that should be taken into consideration when evaluating the performance of public health systems and in the elaboration of realistic working-life extension plans and the design of equitable pension reforms. [ABSTRACT FROM AUTHOR]

The objective of this study was to describe a predictive modeling approach to risk stratify people with type 2 diabetes for diabetes self-management education and support (DSMES) services. With data from a large health system, a predictive model including age, glycated hemoglobin (HbA1c), and insulin use among other factors, was developed to assess risk of future high HbA1c. The model was retrospectively applied to a cohort of people who received DSMES over a 2-year period to assess the impact of DSMES on glycemia by risk strata. Of 6934 eligible people, 4014 (58%) were in the composite low-risk group and 2604 (38%) were in the composite high-risk group. Mean HbA1c change after DSMES was -0.38% in the low-risk group and -0.84% in the high-risk group. This analysis demonstrates the potential application of predictive modeling as one approach to target DSMES resources to people who will benefit most. [ABSTRACT FROM AUTHOR]

Hypertension remains the leading cause of cardiovascular disease globally despite the availability of safe and effective treatments. Unfortunately, many barriers exist to controlling hypertension, including a lack of effective screening and awareness, an inability to access treatment and challenges with its management when it is treated. Addressing these barriers is complex and requires engaging in a systematic and sustained approach across communities over time. This analysis aims to describe the key elements needed to create an effective delivery system for hypertension control. A successful system requires political will and supportive leadership at all levels of an organization, including at the point of care delivery (office or clinic), in the health care system, and at regional, state and national levels. Effective screening and outreach systems are necessary to identify individuals not previously diagnosed with hypertension, and a system for follow up and tracking is needed after people are diagnosed. Implementing simple protocols for treating hypertension can reduce confusion among providers and increase treatment efficiency. Ensuring easy access to safe, effective and affordable medications can increase blood pressure control and potentially decrease health care system costs. Task-sharing among members of the health care team can expand the services that are delivered. Finally, monitoring of and reporting on the performance of the health care team are needed to learn from those who are doing well, disseminate ideas to those in need of improvement and identify individual patients who need outreach or additional care. Successful large-scale hypertension programs in different settings share many of these key elements and serve as examples to improve systems of hypertension care delivery throughout the world. [ABSTRACT FROM AUTHOR]

Clinical pathways (CPs) are interventions that target the way clinical practice guidelines are applied. They can be implemented in different diseases, including diabetes. In this study we evaluated the impact of the implementation of a CP in the control of cardiovascular risk factors and the occurrence of new events in patients with type 2 diabetes. A pre- and post-intervention population-based study in a Spanish region, conducted in 2014–2016. Variables before and after the intervention were: screening; good control of diabetes, dyslipidemia and hypertension; hypoglycemia and hyperglycemic decompensation; obesity; cardiovascular events; diabetic ketoacidosis; hyperglycemic and hypoglycemic coma. Proportional differences and parameters of clinical relevance (absolute and relative risk reduction, relative risk and number needed to treat) were calculated. The CP achieved an improvement in all outcomes, reducing events and increasing control of different cardiovascular parameters. The greatest improvement was in metabolic control (HbA1c) (37.1% in younger patients and 34.0% in older patients) and screening (5.4%). Indicators of clinical relevance showed that the CP was able to improve metabolic control of diabetes with little effort and great benefit. The CP was of considerable benefit to metabolic control as well as control of dyslipidemia and obesity. Screening for diabetes also benefitted. The CP decreased the incidence of events, especially of angina pectoris. [ABSTRACT FROM AUTHOR]

Objective: Frailty is a prevalent risk factor for adverse outcomes among patients with chronic lung disease. However, identifying frail patients who may benefit from interventions is challenging using standard data sources. We therefore sought to identify phrases in clinical notes in the electronic health record (EHR) that describe actionable frailty syndromes.Materials and Methods: We used an active learning strategy to select notes from the EHR and annotated each sentence for 4 actionable aspects of frailty: respiratory impairment, musculoskeletal problems, fall risk, and nutritional deficiencies. We compared the performance of regression, tree-based, and neural network models to predict the labels for each sentence. We evaluated performance with the scaled Brier score (SBS), where 1 is perfect and 0 is uninformative, and the positive predictive value (PPV).Results: We manually annotated 155 952 sentences from 326 patients. Elastic net regression had the best performance across all 4 frailty aspects (SBS 0.52, 95% confidence interval [CI] 0.49-0.54) followed by random forests (SBS 0.49, 95% CI 0.47-0.51), and multi-task neural networks (SBS 0.39, 95% CI 0.37-0.42). For the elastic net model, the PPV for identifying the presence of respiratory impairment was 54.8% (95% CI 53.3%-56.6%) at a sensitivity of 80%.Discussion: Classification models using EHR notes can effectively identify actionable aspects of frailty among patients living with chronic lung disease. Regression performed better than random forest and neural network models.Conclusions: NLP-based models offer promising support to population health management programs that seek to identify and refer community-dwelling patients with frailty for evidence-based interventions. [ABSTRACT FROM AUTHOR]

The SARS-CoV-2 virus that causes COVID-19 has wreaked havoc on the global community in terms of every imaginable parameter. The research output on COVID-19 has been nothing short of phenomenal, especially in the medical and biomedical sciences, where the search for a potential vaccine has been conducted in earnest. Much of the advanced research has been distributed in leading medical journals, including the Journal of the American Medical Association (JAMA), where the latest research is distributed on a daily basis. The purpose of this paper is to provide some perspectives on 44 interesting and highly topical research papers that have been published in JAMA, at the time of writing, within the past two weeks. The diverse topics include public health, general medicine, internal medicine, oncology, pediatrics, geriatrics, and biostatistics. [ABSTRACT FROM AUTHOR]

مقدمه: امروزه افزایش جمعیت و به دنبال آن توسعه کالبدی شهرها، موجب کمبود زیرساخت‌ها و خدمات شهری در مناطق جدید شهری شده است. پژوهش حاضر با هدف ﻣﺸﺨﺺ نمودن ﻧﻮاﺣﻲ ﻣﺤﺮوم از ﺧﺪﻣﺎت درمانی (منطقه 10 شهر شیراز) و ﻣﻜﺎن‌ﻳﺎﺑﻲ بهینه کاربری برای بیمارستان انجام شد. روش بررسی: این مطالعه از نوع توصیفی بود و با رویکرد شهروند محوری انجام گردید. اﻃﻼﻋﺎت ﻣﻮرد ﻧﻴﺎز نیز از طرح تفصیلی منطقه به دست آمد. با طراحی پرسش‌نامه، از 10 نفر متخصصان حوزه سلامت و برنامه‌ریزی شهری درخواست شد تا به 3 معیار و 10 زیرمعیار امتیاز دهند و ارجحیت هر کدام از معیارها را مشخص نمایند. به منظور مکان‌یابی بهینه، از تحلیل سلسله مراتبی و سيستم اطلاعات جغرافيايي GIS (Geographic Information System) استفاده گردید. یافته‌ها: ﺗﺠﻤﻊ ﺑﺴﯿﺎر زﯾﺎد ﮐﺎرﺑﺮی ﺑﻬﺪاﺷﺘﯽ- درﻣﺎﻧﯽ در ﻣﺮﮐﺰ ﺷﻬﺮ شیراز ﺑﺎﻋﺚ ﺷﺪه است که ﻣﻨﺎﻃﻖ ﺷﻤﺎل‌ ﻏﺮﺑﯽ و ﺟﻨﻮب ﺷﺮﻗﯽ با ﮐﻤﺒﻮد ﮐﺎرﺑﺮی درمانی مواجه باشند. پس از بررسی معیارها و زیرمعیارها، بهترین موقعیت‌های مکانی جهت احداث بیمارستان پیشنهاد گردید. نتیجه‌گیری: ﺗﻮزﻳﻊ ﺧﺪﻣﺎت ﺷﻬﺮي و ﺑﻪ ویژه ﺧﺪﻣﺎت درمانی، ﺑﺎﻳﺪ ﺑﻪ ﮔﻮﻧﻪ‌اي ﺑﺎﺷﺪ ﻛﻪ ﻋﺪاﻟﺖ ﻓﻀﺎﻳﻲ رعایت گردد. اراضی بایر و زمین‌های اوقافی، نزدیکی به معابر درجه یک و محدوده‌های با تراکم جمعیتی بالاتر، به عنوان موقعیت‌های برتر جهت مکان‌یابی بیمارستان‌ها پیشنهاد شد.

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Importance: Large gaps in clinical care in patients with chronic kidney disease (CKD) lead to poor outcomes., Objective: To compare the effectiveness of an electronic health record-based population health management intervention vs usual care for reducing CKD progression and improving evidence-based care in high-risk CKD., Design, Setting, and Participants: The Kidney Coordinated Health Management Partnership (Kidney CHAMP) was a pragmatic cluster randomized clinical trial conducted between May 2019 and July 2022 in 101 primary care practices in Western Pennsylvania. It included patients aged 18 to 85 years with an estimated glomerular filtration rate (eGFR) of less than 60 mL/min/1.73m2 with high risk of CKD progression and no outpatient nephrology encounter within the previous 12 months., Interventions: Multifaceted intervention for CKD comanagement with primary care clinicians included a nephrology electronic consultation, pharmacist-led medication management, and CKD education for patients. The usual care group received CKD care from primary care clinicians as usual., Main Outcomes and Measures: The primary outcome was time to 40% or greater reduction in eGFR or end-stage kidney disease., Results: Among 1596 patients (754 intervention [47.2%]; 842 control [52.8%]) with a mean (SD) age of 74 (9) years, 928 (58%) were female, 127 (8%) were Black, 9 (0.6%) were Hispanic, and the mean (SD) estimated glomerular filtration rate was 36.8 (7.9) mL/min/1.73m2. Over a median follow-up of 17.0 months, there was no significant difference in rate of primary outcome between the 2 arms (adjusted hazard ratio, 0.96; 95% CI, 0.67-1.38; P = .82). Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker exposure was more frequent in intervention arm compared with the control group (rate ratio, 1.21; 95% CI, 1.02-1.43). There was no difference in the secondary outcomes of hypertension control and exposure to unsafe medications or adverse events between the arms. Several COVID-19-related issues contributed to null findings in the study., Conclusion and Relevance: In this study, among patients with moderate-risk to high-risk CKD, a multifaceted electronic health record-based population health management intervention resulted in more exposure days to angiotensin-converting enzyme inhibitors/angiotensin receptor blockers but did not reduce risk of CKD progression or hypertension control vs usual care., Trial Registration: ClinicalTrials.gov Identifier: NCT03832595.

Population Health Management - often abbreviated to PHM - is a relatively new approach for healthcare planning, requiring the application of analytical techniques to linked patient level data. Despite expectations for greater uptake of PHM, there is a deficit of available solutions to help health services embed it into routine use. This paper concerns the development, application and use of an interactive tool which can be linked to a healthcare system's data warehouse and employed to readily perform key PHM tasks such as population segmentation, risk stratification, and deriving various performance metrics and descriptive summaries. Developed through open-source code in a large healthcare system in South West England, and used by others around the country, this paper demonstrates the importance of a scalable, purpose-built solution for improving the uptake of PHM in health services., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Aims: This study aimed to present the Johns Hopkins Adjusted Clinical Groups (ACG) System risk stratification profile of a total adult population of somatic health-care users when using data from either general practitioners (GPs) or hospital services and to compare the number and characteristics of individuals identified as having complex and long-term health-care needs in each data source., Methods: This was a registry-based study that included all adult residents ( N =168,285) in four municipalities in Central Norway who received somatic health care during 2013. Risk profiles were generated using the ACG System based on age, sex and diagnoses registered by GPs or the local hospital. ACG output variables on number of chronic conditions, frailty and concurrent resource utilisation were chosen as indicators of complexity., Results: Nearly nine out of 10 (83.9%) of the population had been in contact with a GP, and 35.4% with the hospital. The mean number of diagnoses (3.0) was equal in both sources. A larger proportion of the population had higher risk scores in all variables except frailty when comparing hospital data to GP data. This was also found when comparing individuals identified as having complex and long-term health-care needs. A similar proportion of the population was found to have complex and long-term health-care needs (hospital 6.7%, GP 6.3%), but only one in five (21.5%) were identified in both data sets., Conclusions: As data from GPs and hospitals identified mostly different individuals with complex and long-term health-care needs, combining data sources is likely to be the best option for identifying those most in need of special attention., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Improving the overall care of children with medical complexity (CMC) is often beset by challenges in proactively identifying the population most in need of clinical management and quality improvement. The objective of the current study was to create a system to better capture longitudinal risk for sustained and elevated utilization across time using real-time electronic health record (EHR) data. A new Pediatric Population Management Classification (PPMC), drawn from visit diagnoses and continuity problem lists within the EHR of a tristate health system, was compared with an existing complex chronic conditions (CCC) system for agreement (with weighted κ) on identifying CCMC, as well as persistence of elevated charges and utilization from 2016 to 2019. Agreement of assignment PPMC was lower among primary care provider (PCP) populations than among other children traversing the health system for specialty or hospital services only (weighted κ 62% for PCP vs. 82% for non-PCP). The PPMC classification scheme, displaying greater precision in identifying CMC with persistently high utilization and charges for those who receive primary care within a large integrated health network, may offer a more pragmatic approach to selecting children with CMC for longitudinal care management.

The article explores how health plans are relying on population health management algorithms to identify potentially high-cost, high-utilization patients and target these patients in efforts to improve outcomes or reduce health care costs. Topics include neighborhood-level social determinants of health data to identify patients at high risk for hospitalization or death; and health care utilization and costs were lower for Black patients than White patients with similar health risk factors.

Using a population-based, representative telephone survey, ~930 000 New York City residents had COVID-19 illness beginning 20 March–30 April 2020, a period with limited testing. For every 1000 persons estimated with COVID-19 illness, 141.8 were tested and reported as cases, 36.8 were hospitalized, and 12.8 died, varying by demographic characteristics. [ABSTRACT FROM AUTHOR]

The aim of this study is to evaluate the management capacity of the Specialized Component of Pharmaceutical Services (CEAF, in Portuguese) in the state of São Paulo (SP), according to the organizational, operational and sustainability aspects. The study was designed as an evaluative investigation, with the adoption of a theoretical model and protocol of indicators developed for application at the national level and validated (Nominal Group and Traditional Committee) for application in the reality of the SP. The data collection in the 35 CEAF units was carried out in 2017 and 2018, and covered all technical areas that participate in the management/execution of CEAF, in both its central and regional scopes. The assessment of management capacity was based on a critical analysis of the obtained results, analyzing their strengths and weaknesses. After collecting data from 35 CEAF units, it was found that the management capacity was positive in the operational dimension with challenges concentrated in the other dimensions. The results showed greater investments and development in the technical aspects of pharmaceutical services, but deficiencies in such areas as the monitoring of clinical results, infrastructure, regulation, and communication with the actors involved. [ABSTRACT FROM AUTHOR]

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Background: Type 2 diabetes (T2D) causes substantial disease burden and is projected to affect an increasing number of people in coming decades. This study provides projected estimates of life years free of type 2 diabetes (T2D) and years of life lost (YLL ) associated with T2D for Germany in the years 2015 and 2040. Methods: Based on an illness-death model and the associated mathematical relation between prevalence, incidence and mortality, we projected the prevalence of diagnosed T2D using currently available data on the incidence rate of diagnosed T2D and mortality rates of people with and without diagnosed T2D. Projection of prevalence was achieved by integration of a partial differential equation, which governs the illness-death model. These projected parameters were used as input values to calculate life years free of T2D and YLL associated with T2D for the German population aged 40 to 100 years in the years 2015 and 2040, while accounting for different assumptions on future trends in T2D incidence and mortality. Results: Assuming a constant incidence rate, women and men at age 40 years in 2015 will live approximately 38 years and 33 years free of T2D, respectively. Up to the year 2040, these numbers are projected to increase by 1.0 years and 1.3 years. Assuming a decrease in T2D-associated excess mortality of 2% per year, women and men aged 40 years with T2D in 2015 will be expected to lose 1.6 and 2.7 years of life, respectively, compared to a same aged person without T2D. In 2040, these numbers would reduce by approximately 0.9 years and 1.6 years. This translates to 10.8 million and 6.4 million YLL in the German population aged 40–100 years with prevalent T2D in 2015 and 2040, respectively. Conclusions: Given expected trends in mortality and no increase in T2D incidence, the burden due to premature mortality associated with T2D will decrease on the individual as well as on the population level. In addition, the expected lifetime without T2D is likely to increase. However, these trends strongly depend on future improvements of excess mortality associated with T2D and future incidence of T2D, which should motivate increased efforts of primary and tertiary prevention. [ABSTRACT FROM AUTHOR]

Rationale, aims, and objectives: The health care delivery model in the United States does not work; it perpetuates unequal access to care, favours treatment over prevention, and contributes to persistent health disparities and lack of insurance. The vast majority of those who suffer from preventable diseases and health disparities, and who are at greatest risk of not having insurance, are low‐income minorities (Native Americans, Hispanics, and African‐Americans) who live in high risk and vulnerable communities. The historical lack of support in the United States for Universal Health Care (UHC) and Primary Health Care (PHC)—with their emphasis on health care for all, population health, and social determinants of health—requires community health scientists to develop innovative local solutions for addressing unmet community health needs. Methods: We developed a model community health science approach for improving health in fragile communities, by combining community‐oriented primary care (COPC), community‐based participatory research (CBPR), asset‐based community development, and service learning principles. During the past two decades, our team has collaborated with community residents, local leaders, and many different types of organizations, to address the health needs of vulnerable patients. The approach defines health as a social outcome, resulting from a combination of clinical science, collective responsibility, and informed social action. Results: From 2000 to 2020, we established a federally funded research programme for testing interventions to improve health outcomes in vulnerable communities, by working in partnership with community organizations and other stakeholders. The partnership goals were reducing chronic disease risk and multimorbidity, by stimulating lifestyle changes, increasing healthy behaviours and health knowledge, improving care seeking and patient self‐management, and addressing the social determinants of health and population health. Our programmes have also provided structured community health science training in high‐risk communities for hundreds of doctors in training. Conclusion: Our community health science approach demonstrates that the factors contributing to health can only be addressed by working directly with and in affected communities to co‐develop health care solutions across the broad range of causal factors. As the United States begins to consider expanding health care options consistent with PHC and UHC principles, our community health science experience provides useful lessons in how to engage communities to address the deficits of the current system. Perhaps the greatest assets US health care systems have for better addressing population health and the social determinants of health are the important health‐related initiatives already underway in most local communities. Building partnerships based on local resources and ongoing social determinants of health initiatives is the key for medicine to meaningfully engage communities for improving health outcomes and reducing health disparities. This has been the greatest lesson we have learned the past two decades, has provided the foundation for our community health science approach, and accounts for whatever success we have achieved. [ABSTRACT FROM AUTHOR]